Basic Information
| Provider Information | |||||||||
| NPI: | 1225157696 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPOT 4 KIDS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29D STONEHILL RD | ||||||||
| Address2: | |||||||||
| City: | OSWEGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605439449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305546156 | ||||||||
| FaxNumber: | 6305546378 | ||||||||
| Practice Location | |||||||||
| Address1: | 29D STONEHILL RD | ||||||||
| Address2: | |||||||||
| City: | OSWEGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605439449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305546156 | ||||||||
| FaxNumber: | 6305546378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | VANBOEKEL | ||||||||
| AuthorizedOfficialFirstName: | ELISABETH | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6305546156 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 4520064 | 01 | IL | BCBS OF ILLINOIS | OTHER |